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Early Alert Referral Form - Counseling Department

Early Alert is a program designed to help students be successful at Ohlone College. A counselor will follow up with every student referred.

Instructions for Faculty: Please complete this form knowing the information you provide may be shared with the student.

Asterisk (*) indicates a required field.

Instructor Information

* First and Last Name:

* Telephone Number: (Include area code.)

* Email Address:

Course Information

* Department / Course:

* Which campus is this course on?:(Select all that apply.)

Fremont Campus

Newark Campus

Online

Other/Off-Campus

At a minimum, please provide name, Student ID Number, and academic problem cause(s) for each student you are referring.

Student #1

Referral for Student #1

First Name:

Last Name:

Ohlone Student ID Number: (7 digits. Do not use a Social Security Number.)

Telephone Number: (Include area code.)

Email Address:

Student is encountering academic problems due to one or more of the following: (Select all that apply.)

Ability/Preparedness: Reading

Ability/Preparedness: Writing

Ability/Preparedness: Computation

Tardiness/Absences

Working/Class Conflict

Low Test Scores

Personal or Financial Problems

Motivation/Attitude

Language (non-native)

Other

Other probable cause - please describe:

Student #2

Referral for Student #2

First Name:

Last Name:

Ohlone Student ID Number: (7 digits. Do not use a Social Security Number.)

Telephone Number: (Include area code.)

Email Address:

Student is encountering academic problems due to one or more of the following: (Select all that apply.)

Ability/Preparedness: Reading

Ability/Preparedness: Writing

Ability/Preparedness: Computation

Tardiness/Absences

Working/Class Conflict

Low Test Scores

Personal or Financial Problems

Motivation/Attitude

Language (non-native)

Other

Other probable cause - please describe:

Student #3

Referral for Student #3

First Name:

Last Name:

Ohlone Student ID Number: (7 digits. Do not use a Social Security Number.)

Telephone Number: (Include area code.)

Email Address:

Student is encountering academic problems due to one or more of the following: (Select all that apply.)

Ability/Preparedness: Reading

Ability/Preparedness: Writing

Ability/Preparedness: Computation

Tardiness/Absences

Working/Class Conflict

Low Test Scores

Personal or Financial Problems

Motivation/Attitude

Language (non-native)

Other

Other probable cause - please describe:

Student #4

Referral for Student #4

First Name:

Last Name:

Ohlone Student ID Number: (7 digits. Do not use a Social Security Number.)

Telephone Number: (Include area code.)

Email Address:

Student is encountering academic problems due to one or more of the following: (Select all that apply.)

Ability/Preparedness: Reading

Ability/Preparedness: Writing

Ability/Preparedness: Computation

Tardiness/Absences

Working/Class Conflict

Low Test Scores

Personal or Financial Problems

Motivation/Attitude

Language (non-native)

Other

Other probable cause - please describe:

Student #5

Referral for Student #5

First Name:

Last Name:

Ohlone Student ID Number: (7 digits. Do not use a Social Security Number.)

Telephone Number: (Include area code.)

Email Address:

Student is encountering academic problems due to one or more of the following: (Select all that apply.)

Ability/Preparedness: Reading

Ability/Preparedness: Writing

Ability/Preparedness: Computation

Tardiness/Absences

Working/Class Conflict

Low Test Scores

Personal or Financial Problems

Motivation/Attitude

Language (non-native)

Other

Other probable cause - please describe:

A counselor will contact you if more information is needed.

Your privacy is important to us. Your personal information will not be sold or shared with unaffiliated third parties except as necessary to maintain and process client accounts or when the law requires it.